To Be Completed by the Practitioner Or SENCO (Maintained Nurseries: Please Discuss With

To Be Completed by the Practitioner Or SENCO (Maintained Nurseries: Please Discuss With

To be completed by the Practitioner or SENCO (Maintained Nurseries: Please discuss with your link EP first)

Name of Child: ………………..…………………………………………………………………

Date of Birth: ……………………………………………………………………………………

Ethnicity (Please complete attached form)

Setting: ……………………………………………………………………………………………

Name of SENCO/Practitioner: …………………………………………………………………

Contact Details: ……………………………………………………………………………………………

Family Contact Details:

Name of Parent/Carers: ……………………………………………………………………………….

Parent/ Carers Address ………………………………………………………………………………..

Postcode ……………………………………………………………………………………

Parents/ Carers Telephone numbers: …………………………………………………………………………………………..

Minimum criteria for EP involvement:

  • Individual Play Plan or equivalent in place
  • At least one outside agency already working with the child

Priority for EP involvement will be given to children starting school in September 2017, and those requiring specialist provisions from the age of 2 years.

Please return the form to:

Jenny Kraft, Educational Psychologist,

The Meadow, Leigh Road, Penhill, Swindon, SN2 5DE

e-mail:

You will be notified within two weeks of receipt of this request whether EP involvement has been agreed.

Please attach the following, and tick as appropriate:

□ Individual Play Plan or equivalent

□ EYFS Developmental Chart

□ Any relevant professional reports. Please specify: …………………………………………………..

□ Early Help Record (if one completed)

□ This request for possible EPS involvement has been agreed by parents/carers. Please note we are not able to accept all requests for service.

Name of Health Visitor: ______

To your knowledge, have they completed a Schedule of Growing Skills? Yes/No

To support us in considering your request for service, please provide the following information:

Developmental Areas
Please comment on the child’s development in the following areas: / Practitioners/Services involved
Highlight as appropriate / What advice/support has been given?
Communication and Language / Speech and Language Therapist
Paediatrician
Advisory Teacher for Social Communication and Interaction Difficulties (SCID)
Other: ………………………….
Physical Development / Advisory Teacher for Physical and Sensory Difficulties
Paediatrician
Occupational Therapist
Physiotherapist
Other………………………………
Approach to Play and Learning / Early Years Consultant
Portage/Koalas /Special Tots
Children’s Centre
Other………………………………
Personal, Social and Emotional development / Nyland Campus
Targeted Mental Health Service
Other……………………………….

Describe the progress made from the support offered:

Signed by Parent/Carer……………………………………………………………………………..

Completed by: …………………………………………………………………………………………..

Role: ………………………………………………………………………………………………………….

Date: …………………………………………………………………………………………………………

Phone Number & email: ………………………………………………………………………………………..


/ Revised
24August / 2015
Children, Young People and Families Service Consent Form
Child / Young Person’s Name: / D.O.B.
Parent Carers Name: /
From our work with you, we will hold information about you and your family on our electronic data base. For example demographic information such as; name, address, sate of birth, ethnicity. We will also hold details of meetings you attend, assessments, plans and case information.
More detail is included in the privacy notice.
Your worker would like your permission to share with and / or gather information from other service areas within the council and with external service providers as appropriate to meet your needs.
Are there any services that you do not wish us to contact:
If Yes: / Please specify:
/ Yes / No
/ Using your Personal Information
/ The information you provide will be held on our database to help monitor the service we provide. We share and or gather information from private and voluntary organisations who may be involved in working with you and your family.
Please note the only reason that information will be passed on without your consent is if there is a legal requirement to do so, or if there is a risk of serious harm or threat to life.
Under the Data Protection Act you can see your own personal information. If you would like to know more about this, please ask for our leaflet 'Access to your personal information'. Or contact the Data Protection Officer at Swindon Borough Council Civic Offices, Euclid Street, Swindon SN1 2JH
Signed to give your consent
I understand & agree to the sharing of information as shown above.
Signed (Young Person / Parent/ Carer) / Signed (Worker)
Date …………..…..………… / Date …………..…..…………

Children, Families and Community Health

SWINDONEDUCATIONAL PSYCHOLOGY SERVICE

CONTRIBUTION BY PARENT/CARER FOR A CHILD/PUPIL

What is your ethnic group?Choose ONE section from A to E, and then tick the appropriate box to indicate your ethnic group.

A: White

  • British
  • Irish
  • Any other White background

(please write in) ………………………………..

B: Mixed

  • White and Black Caribbean
  • White and Black African
  • White and Asian
  • Any other mixed background

(please write in) ………………………………….

C: Asian or Asian British

  • Indian
  • Pakistani
  • Bangladeshi
  • Any other Asian background

(please write in) …………………………………….

D: Black or Black British

  • Caribbean
  • African
  • Any other Black background

(please write in) …………………………………….

E: Chinese or other ethnic group

  • Chinese
  • Any other (please write in) ……………………………………..

This page is supposed to be BLANK

Please hand the following sheet to

Parent, Carer and/or Young Person

Revised 24 August 2015

Children, Families and Community Health

How information about you will be used

Why organisations keep and share information about you and your child

Swindon Borough Council provides a range of community health, social care and early help services such as the Youth Engagement Service and Education Support Services. This in an integrated children’s service and is called Children, Families and Community Health. It also works with families as part of the Troubled Families national initiative.

This Service and Swindon’s Children Centres hold information on paper and on an electronic database about your family, if you are in receipt of a service. Once your information is on the database, other professionals within Swindon Borough Council Children Services will be able to see which services you are accessing and case information. Staff need this information so they can give the best advice possible and offer support.

Individual case information will not be shared outside of the Children’s Service unless consent has been given, or there is a risk of significant harm to a person. General demographic data such as; name, address,date of birth, ethnic group and special educational needs will be shared between organisations that provide public sector services in Swindon and form together as the One Swindon Partnership. The One Swindon Partnership includes a range of health care providers and local council services.

Further information about how organisations use your information can be found at the following website in the document “Contact details and data sharing between organisations”.

http://www.swindon.gov.uk/cd/cd-dataprotection/Pages/cd-dataprotection.aspx

If you are concerned in relation to data sharing and would like to opt out of allowing us to share information, you can contact us by:

Email:

or

Letter: Data Manager,

Children Services Information and Performance Team

Swindon Borough Council

Civic Offices

Euclid Street

SN1 2JH

Top View